Workers Compensation
Compensability is the initial step in the processing of any Worker’s Compensation claim. It is the step that will lay the foundation for a claim’s legitimacy – or its denial. For our purposes, compensability is the gathering of information about the claimant, the circumstances, and the nature of the claim. A compensability statement that is properly and completely done should, in the event of a fraudulent claim, provide all the necessary information needed to deny and perhaps even prosecute the offender.
Field Investigators conduct the bulk of claims investigations. The investigation process typically will include employer interviews, taking of statements from witnesses, injured worker, and other parties. We seek to establish any information or fact which may be relevant to the claim including the history and background of the injured worker. Outside factors which may have an influence on the claim, or other credibility issues might also be explored.
An objective report, based on fact, and supported by documented evidence, provides you with pertinent information necessary to consider when making the determination on the claim. Supportive documentation gathered for you may include payroll, and attendance records, employment application, and other personnel records, as well as any company policies and procedures. Credibility issues may be supported by other external witness statements, such as past employers, friends, relatives or by other external witness statements, such as past employers, friends, relatives, or by other documents that might include items such as police or court records.
Field investigations are appropriate when there is visual need for in-person, on-site investigations to gather the information necessary for claim decision, or when in person interviews are indicated. Most attorney represented worker interviews are conducted by the field investigators. Field investigators frequently conduct activities checks and may locate worker or witnesses.
Consider an investigation when questions of compensability or responsibility arise, you find conflicting information in reports, there is questionable medical causation, or there may be third party potential.
Activity Checks
Separating Fact From Fiction.
An Activity Check investigation should determine whether an individual’s level of activity is or is not consistent with their claimed condition and restrictions. The goal is to know more about the worker when you finish than you did when you started.
An investigation request may be initiated for any of several reasons, for example:
- Recovery time is longer than normally associated with type / severity of injury
- Leads / rumors indicate worker is active while on time loss
- Reports (medical / vocational / other) give indications of activity
- Lack of cooperation from worker (i.e. not attending medical appointments, not attending vocational training, not cooperating with ERTW efforts)
- Compensability decision depends on confirming rumored or alleged activity
- There are indications of home-based self-employment
- Confirmation of activity level for purposes of establishing accurate disability ratings
Good results depend on good case preparation. Know the history of the case and the issues to be resolved. Most importantly, know your subject before you go out. You need to know the type of injury, body part involved, current medical condition or diagnosis, physical limitation(s) or restriction (s) (use of cane / crutches, etc.), and have a good physical description of the worker.
Case preparation going out in the field should include:
- Contact adjuster if necessary
- Review medical reports if available, PCEs, IMEs, vocational reports
- Current work status; days / hours / limitations if on modified duty
- Treatment status; who / where / when / how often
- Contact employer or coworkers for physical description if unknown; also, for leads as to worker’s interests, and hobbies
Surveillance
Seeing is Believing.
Experience has shown us that some injured workers will prolong their return to work by malingering or their disabilities. Surveillance investigations should be initiated when you have good reason to believe the worker is misrepresenting their disability, and when visual evidence can be utilized in closing or managing the claim. In those instances, conducting covert surveillance and gathering video evidence of the injured workers disability and activity level is necessary to manage the claim effectively and avoid paying undeserved benefits.
Surveillance video may also be beneficial or necessary in some cases for establishing evidence that supports a fraud investigation and resulting in criminal prosecution. The goal in the fraud investigation is to determine whether fraudulent activity has occurred and to identify the course of action that should be pursued. That may lead to a recovery method that would include collection of monies owed, or civil / criminal prosecution.
There are three main categories of fraud investigations: worker, employer, and provider. You may recognize the indicators when dealing with the injured worker, but there are other red flags that may alert you to the need for further investigation or other types of possible fraud.
Effective surveillance reduces the paid costs on claims!
Case Assignment
We’ll Take It From Here.
NOTE: This page consists of a form that gets emailed to someone@ppisecurity.com (actual email is to be determined). Some of the form elements (to be determined) are required to be filled in before the form can be submitted. The Category Headers are descriptors of the form elements below them.